Full Text Review
Please note: In 2003, the CTF updated its Grades of
Recommendations to include an "I Recommendation" for situations where
insufficient evidence exists to allow a recommendation to be made.
(Formerly, these situations were captured under a "C
Recommendation".) This change is not retroactive, and all
"C Recommendations" made prior to 2003 have not been
reevaluated in light of the new "I" recommendation grade. For a
discussion of these recommendation grades, please link to the 2003 article in
the Canadian Medical Association Journal here.
Prevention of Household and Recreational Injuries in the
Elderly
Prepared by R. Wayne Elford, MD, CCFP, FCFP, Professor
and Director of Research and Faculty Development, Department of Family
Medicine, University of Calgary, Alberta
These recommendations were finalized by the Task Force in June 1993
Contents
Overview
In the 1979
Canadian Task Force report, home and recreational injuries were acknowledged
to constitute an important proportion of accidents. The report emphasized
the particular risk for the elderly.< 1>
At that time there was insufficient literature on the subject to justify
a recommendation on scientific grounds. This lack of evidence persists
for most areas of injury prevention among the elderly. New evidence has
emerged, however, supporting multi-disciplinary post-fall assessment where
this service is available. Accidental injury and death caused by motor
vehicle accidents (46.5% of all deaths due to accidents) is covered in
a separate chapter (Chapter 44).
Burden
of Suffering
The seven leading causes of unintentional death in Canada
are falls (21%),
drowning (6.4%), burns, fire-related injuries (4.8%), suffocation (4.7%),
poisonings (4.7%), bicycle and sports-related injuries (1.7%),
and firearms (0.7%).<2> Injuries sustained in falls are a major cause
of mortality and morbidity in the elderly population.<3> Table 1
summarizes
the Canadian mortality and morbidity rates for various types of injury
in the elderly. A brief description of the risk factors associated with
each of the leading causes of unintentional injury in the elderly is provided.
Falls
In 1988
there were 2,100
deaths due to falls.<2> Falls resulting in serious injury or death were
much more frequent among those aged 55 and over; 70% of fatal falls were
among persons 75 years and over.<4> Ninety-five percent of injuries
among the elderly living in long-term care facilities were due to falls.<5>
One percent of falls by individuals aged 65 and over result in hip fracture.
A descriptive study found fewer than 30% of 219
women aged 59 and over with hip fractures regained reported pre-fracture
levels of physical function. Also, high post-surgery depression scores
were associated with poorer recovery. A case-control study of 149
institutionalized and 68 non-institutionalized elderly persons (15%
female and 87% male respectively), matched by age, sex and living location,
found fallers were more physically and functionally impaired with hip weakness,
poor balance and more medications predictive of falls in institutionalized
patients (logistic regression p<0.05). Falls without fracture are among
the most common causes of admission of the elderly to geriatric hospitals,
residential homes and nursing homes, often due to family concerns about
safety, restricted mobility and independence. Risk factors for falling
include increased age, female sex, presence of more than one disease, dementia,
depression, acute illness, decreased mobility, confinement to the home,
postural gait instability, gait disturbance, sensory impairment, medications
and possibly dietary deficiencies.<6>
Drowning
In 1987
there were 429 deaths due to drowning in Canada, including 135
boating accidents. Only 12%
of drowning victims were over 65 years of age.<7>
Burns, Scalds
and Fire-Related Deaths
There were 429 fire-related deaths in Canada in 1987
and 85% occurred in private dwellings.<4> Of the 402 accidental deaths
among Canadians caused by fire and flames in 1988,
about 21%
involved persons over 65 years of age.<7> The number of fires and fire
deaths (844 in 1978)
has declined continually and has been attributed to better education, more
widespread use of smoke detectors and fewer people smoking.<8>
Poisoning
Of the 424 fatal poisonings in Canada in 1987,
16%
of the deaths were among seniors over 65 years of age.<4,7> Most were
by drugs and medications (58%); 23% were by solid and liquid substances
and 19% by
gases and vapours. Among elderly adults, sedatives are the most commonly
reported agents causing morbidity.
Suffocation
Almost two-thirds of the 415
Canadian deaths by suffocation in 1987
resulted from inhalation and/or ingestion of food; 13%
were in adults over 65 years of age.<4,7>
Effectiveness
of Prevention Maneuvers
During the past decade numerous descriptive studies
concerning home and recreational accidents have been published. More important
however, is the steady stream of experimental and quasi-experimental studies
demonstrating that accidental injury and death are not random, unpredictable
events, but are both predictable and preventable<9> and must be looked
upon as a disease whose prevention must be approached scientifically. One
model for organizing preventive measures against accidental injury and
death is the Haddon Matrix,<10>
named after a leading thinker in injury control. The Haddon Matrix for
generating countermeasures provides a multifactorial model for developing
approaches to injury prevention.<10>
Three widely adopted approaches to interventions for accidental injury
arising from this model are described in greater detail; namely, public
health education, environmental legislation, and individual counselling.
Public Health
Education
In general, modifying the environment appears to be
more effective than trying to change human behaviour among the elderly.
Legislative/Environmental
Many studies have demonstrated a far greater impact
on promoting home and recreational safety by influencing legislators, who
in turn can modify the environment through building codes and safety legislation
(Table 2).
Individual Counselling
The "Year 2000 Injury Control Objectives for Canada"
recommend that individual counselling be targeted particularly towards
high risk groups; namely, the socio-economically disadvantaged, the aboriginal
people, situations where alcohol and/or substance abuse is suspected, and
the elderly living alone.<16>
Evidence concerning the effectiveness of legislative action and individual
counselling for these activities will be presented sequentially for each
major type of home and recreational injury.
Falls
Systematic identification and reduction of environmental
hazards prevents injuries. As with other unintentional injuries, modifying
the environment (stairs, especially those with undifferentiated edges,
slippery floor, surface clutter, poor lighting, unexpected obstacles and
ill-fitting footwear) can be far more effective than trying to change the
behaviour of people living in that environment. Several checklists for
home safety evaluation<17>
and for studying the epidemiology and risk of falls have been published,
but none has been evaluated in clinical practice. Exercise programs have
demonstrated positive effects on the muscle strength, flexibility, and
cardiovascular and respiratory systems of older people. Physiotherapy improved
mobility and balance in one third to one half of 100
patients over age 65 who had recently fallen; less than one half of patients
fell in the 4 months following treatment. Recreational walking appeared
to reduce the risk of fracture in a cohort of elderly persons.
A Falls Clinic, coordinating the expertise of a geriatrician,
neurologist, cardiologist and psychiatrist, combined with resources in
audiology, ophthalmology and podiatry as well as home visits by an occupational
therapist eliminated falls for 1 year
in 77% of patients who had fallen previously.<6,18>
Another randomized controlled trial of a post-fall assessment, including
a detailed physical examination and environmental assessment by a nurse
practitioner, laboratory tests, electrocardiogram and 24-hour Holter monitoring
reduced hospitalizations by 26% (p<0.05) and hospital days by 52% (p<0.01)
for 160 elderly
ambulatory residential care facility patients but did not significantly
decrease falls reported on nursing incident reports (9% lower) or deaths
(17% lower)
with 2 years of follow-up.<19>
Recommendations for rehabilitation therapies were given to 60% of intervention
subjects. Recommendations for environmental alterations were made for 45%
and alterations in medication for 43%. The authors concluded that though
falls may not be easily prevented, they indicate the presence of important
treatable conditions and some of the disability and costs associated with
falls may be obviated by a thorough assessment.
An 1989
review indicated there were no controlled studies demonstrating the effectiveness
of detecting disease, changing medication, promoting exercise, initiating
home nursing visits to assess environmental hazards, educating patients,
counselling on medication use, physical therapy or balance and gait training
on reducing falls.<17>
Burns
"Granny gown" burns among elderly women are still a
common problem. Cooking-related flame burns can be reduced by encouraging
the independent elderly not to wear loose fitting garments in the kitchen,
not to keep condiments or spices over the stove and to use the rear rather
than front burner while cooking.<20> The only evidence with respect
to the effectiveness of counselling on burn prevention in the elderly was
at the level of expert opinion – "The physician can help reduce the incidence
and the severity of fire and burn injuries by reviewing precautions with
his elderly patients and their families and by stressing basic first aid
procedures and the need for immediate medical attention, since even small
burns can become serious if not properly treated."<21>
Recommendations
of Others
In 1989,
the U.S. Preventive Services Task Force recommended that it may be clinically
prudent to provide counselling on measures to reduce the risk of unintentional
household or environmental injuries from falls, drowning, fires or burns,
poisoning, and firearms.<22>
The following recommendations from the National Institute
of Aging<17>
to primary care physicians concerning older patients are based on expert
opinion only:
-
Assess for falls as a routine part of a physical history
for those aged 65 years or older (as if falling is expected).
-
Assess for underlying disease.
-
Observe for sway or unsteady gait, using the equivalent
of the "Get up and go test".
-
Weigh the benefit of each drug against its potential
for contributing to falls; use those less likely to impair balance and
gait.
-
Have a checklist of environmental hazards that a health
educator or nurse can review with the patient. Assess home when appropriate.
-
Encourage the use of handrails and adequate lighting
on stairs and in bathrooms. Advise marking the edges of steps so that they
are clearly recognizable.
Conclusions
and Recommendations
There is good evidence for referring elderly patients
to multidisciplinary post-fall assessment teams, where such a service is
available (A
Recommendation).<6,18>
On the other hand, there is insufficient evidence to support including
assessment and counselling of elderly patients for the risk of falling
in the routine health examination of the elderly (C
Recommendation). It may be included, however, on other grounds. There
is fair evidence that safety aids reduce the incidence and severity of
injuries in the elderly<19>
(B Recommendation),
however, there is insufficient evidence to support counselling elderly
patients and their families about acquisition of safety features, such
as stair railings, bath tub railings, nonflammable fabrics. Such counselling
may be included in the periodic health examination on other grounds (C
Recommendation).
Unanswered
Questions (Research Agenda)
The Haddon Matrix for generating countermeasures provides
a model for planning research. The "human" sector presents a major challenge
for behavioural medicine (e.g., medication prescribing practices in the
elderly). Much remains to be learned about lifestyle patterns and behaviour
change strategies. It is in this last area that individual practitioners
spend most their time and energy. The "timing" of health education messages,
the effectiveness of different motivational techniques, the counselling
skills required by health care providers, and the atmosphere most conducive
to anticipatory care, all require further elucidation.
Evidence
This review deals with household and recreational injuries
without considering occupational or aviation related injuries. These limitations
were incorporated in the MEDLINE search strategy: accidents as a major
mesh heading under the subheadings diagnosis, economics, epidemiology,
law and jurisprudence, mortality, prevention and control, standards and
trends; and not aviation, occupational or traffic accidents. References
were identified for the years 1981
–
November 1991.
Other sources included Statistics Canada, Health and Welfare Canada, the
Insurance Bureau of Canada the Poison Control Centre, supporting documents
of other recommending bodies and references from identified literature.
This review was initiated in January 1991
and
recommendations were finalized by the Task Force in June 1993.
Table
1: Canadian Mortality and Morbidity Rates for Unintentional Injury in 19891
(per 100,000 – standardized to 1971 population)
|
Overall
(0-85+ yr) |
Elderly
(> 65 yr) |
|
Mortality |
Morbidity |
Mortality |
Morbidity |
|
M |
F |
M |
F |
M |
F |
M |
F |
| Falls |
6.77 |
4.16 |
425.0 |
384.0 |
59.15 |
45.32 |
1,446.5 |
2,161.8 |
| Drownings |
2.31 |
.63 |
2.78 |
1.38 |
2.81 |
.97 |
1.26 |
.57 |
| Burns/Fire related |
2.11 |
.91 |
11.52 |
4.23 |
5.39 |
2.33 |
12.82 |
7.02 |
| Poisonings |
1.88 |
.90 |
38.84 |
35.19 |
2.13 |
1.35 |
70.99 |
65.25 |
| Suffocations |
.72 |
.21 |
.39 |
.15 |
.31 |
.12 |
.17 |
.12 |
| Firearms |
.57 |
.04 |
4.69 |
.52 |
.17 |
.05 |
1.27 |
.09 |
1extracted
from data Bureau of Chronic Disease Epidemiology, Laboratory Centre for
Disease Control, Health and Welfare Canada
Table
2: Sample Legislative Measures to Reduce Environmental Hazards
|
Injujry Prevention Maneuver
|
Quality of Evidence
|
Recommendation
|
| SMOKE DETECTORS: Require
that working smoke detectors be maintained in all dwellings.<8> |
II-1
|
B
|
| PREVENTION OF FALLS: Modify
steps and stairs to decrease the likelihood that falls will occur.<6> |
II-1
|
B
|
| DESIGN FOR SAFER PLAYGROUNDS:
Require
playgrounds and play equipment to conform to Commission safety standards.<11> |
II-1
|
B
|
| FENCING AROUND POOLS:
Reqire
that all pools, private and public, be fenced on all four sides, to reduce
the risk of drowning.<12> |
II-2
|
B
|
| WATER HEATER, THERMOSTAT
CONTROL AND TAP WATER ANTI-SCALD DEVICES: Require thermostats to be
set no higher than 120°F, when a new tenant occupies a dwelling or
at any other specified time.<13> |
II-1
|
B
|
| ANTI-POISONING PACKETS:
Distribute
kits including ipecac, cabinet latches, emergency phone numbers, etc. to
all new parents.<14> |
II-2
|
B
|
| BICYCLE SAFETY: Require
riders to wear helmets, particularly while riding on city streets or sidewalks.<15> |
II-1
|
B
|
Full Citation
Link to Structured Abstract of
this review
Link to Summary Table of this
review
Link to Selected References list of this review
Link to 1994 chapter:
Prevention of Household and Recreational Injuries in Children (<15 years of
age)
Link to 1994 chapter: Prevention
of Household and Recreational Injuries in Adults
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